Access to medical records

Patient Details

The person whose records another individuals(s) is to be given access to

Sex:

Male

Female

Indeterminate

Details of person to be given access to this Patient’s information

If more than one person is to be given access then please submit one form per person.

Full Name: *

Relationship to Patient: *

Address: *

Please detail below if the above access is to be limited in any way (e.g. only for test results, only for making & cancelling appointments or for a specified time period only)

*

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Signature:

Date:

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Patient Details

Details of person to be given access to this Patient’s information